Surgery for Sinusitis

Most patients can be treated without surgery, but occasionally surgery must be done. Since part of the problem in sinusitis is an obstruction to the drainage of the sinuses, sometimes the blockage needs to be removed. In that case surgery may be the only means to do so, but it is important to recognize that the prestigious Cochrane Review states that surgery does not offer an advantage over medical treatment. It is also important to recognize that surgery is not meant to solve the problem. Whatever caused the sinusitis will still be present after surgery, and so it is important for any patient who has had surgery to have medical treatment as well

The most common reason to do surgery is due to failure of medical management after an appropriate period of time. In other words, symptoms persist despite optimal medical therapy. Absolute indications for surgery have been established by the American Academy of Otolaryngology-Head and Neck Surgery and include complete obstruction by polyps, spread of infection or abscess into the brain, the area surrounding the eye, or frontal sinus (Pott's puffy tumor), mucocele, fungal sinusitis, tumor or fluid leak from the brain. Other circumstances depend on whether medical management has been successful. It is critically important to recognize that the definition of "failure of medical management" is not well defined. It can mean a week of antibiotics or it can mean an extended evaluation and course of treatment for several months. Needless to say, the percentage of patients who need to have surgery is dependent on the extent of medical management. We typically will refer only a handful of patients for surgery in any given year.

Your surgeon will give you detailed instructions about what medications you may or may not take before surgery. Aspirin, Advil, Aleve and other similar drugs may cause problems with bleeding. Make sure that you discuss all medications which you take including vitamins, minerals, herbal and other supplements. All can potentially adversely affect the surgery.

Surgery is usually done as an outpatient, with most patients going home the same day. The surgery itself usually takes 1-3 hours and a similar amount of time is spent in the recovery room.

Surgery is typically done using a rigid metal endoscope, which allows the surgeon to view the inside of the nose while performing surgery at the same time. An image of the view provided by the endoscope is contained in the image-guided surgery section of this web site. It also may be done using a special catheter over which a balloon is slipped which is then used to enlarge the hold (ostium) from the sinuses.

Surgery is typically done using either local or general anesthesia. When general anesthesia is given, the patient is unable to breathe for themselves, and a tube must be put into the airway to allow the anesthesiologist to breathe for the patient. With local anesthesia, the patient typically is able to breathe by him/herself, but is generally unaware of anything that is occurring. When I had my surgery, I had local anesthesia, and did not remember anything during the procedure except for a few seconds when I was vaguely aware of something going on around me. I was drowsy for several hours afterwards and was not fully awake until the next morning. You may discuss with the surgeon his/her preferences for you regarding anesthesia. Many surgeons prefer to use local anesthesia if it is possible.

Image-guided surgery, discussed elsewhere in this site, may be helpful in situations where complications might otherwise occur because of difficulty with recognizing the usual anatomy. Such is common in the case of frontal sinus disease, or in patients who need to be re-operated.

After surgery is done, you will typically be carefully followed over 4-8 weeks, to make sure that there is no scarring. Typically patients are seen every week or two after the surgery. At that time. crusting will be removed, which can at times be somewhat painful. If crusting is not removed frequently enough, patients may be more likely to have scarring. That being said, there are patients who tend to form scars more frequently despite the best efforts of the surgeon. Many surgeons find that they do not have to use packing after surgery, and consequently reduce the amount of pain with postoperative care. It is not unusual for surgeons to put splints in the nose to keep the nose more open. These are usually removed after a week or so. Sometimes a foam gel will also be used.

Usually patients are given instructions to not fly for 10 days to several weeks, not lift heavy objects and to put ice over the nose and eyes for the first 48 hours. You will often be instructed to not blow your nose for several days. You will also be given instructions about what to do if you need to sneeze and what to do about your medications. Most sinus medications are not continued in the immediate postoperative period with the exception of decongestants and antibiotics. Your surgeon will typically tell you not to irrigate for a week or so after surgery, and to not take NSAIDS or other agents which might cause you to have problems with bleeding.

Most patients find that they will sleep for most of the first 24-hour period, and usually be in bed for a few days. It is typically helpful to have someone around for the first several days who can take care of any needs. Most patients end up going back to work after 1-2 weeks.

It is important to make sure that the surgeon you choose has the ability to perform surgery which is complicated. Unfortunately, many otolaryngologists do not have the ability to perform surgery optimally. A surgeon must perform several hundred endoscopic surgeries before the complication rate is minimized. In addition, the surgeon must perform many operations per year in order to maintain skill. The surgeon who performed surgery on me typically does several hundred endoscopic sinus surgeries per year.

There are many new surgical techniques which can be used for treatment of sinusitis. One popular technique is the "balloon sinuplasty" technique, in which a balloon is placed inside the narrow opening (ostium) into the sinus and then blown up in order to enlarge the opening of the sinus. This is especially helpful in opening the ostium into the sphenoid and frontal sinuses. There have been reports, however that when used to open the maxillary sinus, there is an extra opening made, which can potentially cause problems. (See the section in on the Sinusitis After Surgery page.)

It is not unusual for patients to have some amount of pain after surgery, often requiring narcotics. This should diminish rapidly within a few days, so that typically most patients are able to go back to work and resume normal activities after 1-2 weeks. If this does not happen, the reasons should be investigated. Typically, most patients are at 90% of normal within 6 weeks.

Some patients are led to believe that the surgery will resolve their sinusitis. Occasionally this may happen, but it is more common that continued medical treatment is needed. In addition, under the best hands in surgical studies which have been published, 15% of patients still needed to have more surgery, and that was in the best hands.

For more information on surgery and the complications afterwards, please go the the next section.

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